While performing an assessment, the nurse presses the client's arm with the tip of her thumb, holds for a few seconds, and releases. The nurse observes the client as shown. What is the nurse assessing?
Pitting edema
Capillary refill
Skin temperature
Peripheral pulses
The Correct Answer is A
A. Pitting edema: Pressing on the skin and observing how it rebounds (if it leaves an indentation) is used to assess for pitting edema, which indicates fluid retention in the tissues.
B. Capillary refill: This test involves pressing on the nail beds and observing the time it takes for color to return, not pressing on the arm.
C. Skin temperature: This is assessed by palpating the skin, not by pressing with the thumb.
D. Peripheral pulses: This involves palpating pulse points to assess their presence and strength, not pressing on the arm to check for edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Second or third intercostal space at the left sternal border: Erb's point is located here, and it's a key area for listening to heart sounds, particularly the aortic and pulmonic valves.
B. The second intercostal space at the right sternal border: This area is typically used to auscultate the aortic valve.
C. Fifth intercostal space near the left midclavicular line: This area is used to auscultate the mitral valve, not Erb's point.
D. Third intercostal space at the left sternal border: This is the location for listening to the pulmonic valve, not Erb's point.
Correct Answer is A
Explanation
A. Pitting edema: Pressing on the skin and observing how it rebounds (if it leaves an indentation) is used to assess for pitting edema, which indicates fluid retention in the tissues.
B. Capillary refill: This test involves pressing on the nail beds and observing the time it takes for color to return, not pressing on the arm.
C. Skin temperature: This is assessed by palpating the skin, not by pressing with the thumb.
D. Peripheral pulses: This involves palpating pulse points to assess their presence and strength, not pressing on the arm to check for edema.
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